Wiki E/M Consult Codes and ROS

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lindalouise55

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I have a question about inpatient consults. I am coding for a general surgeon who is often called to consult on an inpatient case. Since we don't use consult codes for Medicare and we are using initial hospital codes my question is doesn't the surgeon have to include a ROS with his dictation? He dictates an HPI, PFSH, Exam and Assessment and Plan but no ROS. If there is an ROS in the EMR can he refer to that in his dictation or must he dictate it. I would appreciate all help with this one as I will have to show him in writing where it says he must dictate one if he has to. He won't take my word for it.

Thanks everyone. :eek:
 
lindalouise55 said:
I have a question about inpatient consults. I am coding for a general surgeon who is often called to consult on an inpatient case. Since we don't use consult codes for Medicare and we are using initial hospital codes my question is doesn't the surgeon have to include a ROS with his dictation? He dictates an HPI, PFSH, Exam and Assessment and Plan but no ROS. If there is an ROS in the EMR can he refer to that in his dictation or must he dictate it. I would appreciate all help with this one as I will have to show him in writing where it says he must dictate one if he has to. He won't take my word for it.

Thanks everyone. :eek:
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Check your MAC's website for guidance. Here's an example of mine, from Novitas. See Question #15. Some allow elements from the HPI to be used towards ROS.

http://www.novitas-solutions.com/we...es%2FMedicareJH&_adf.ctrl-state=rclul8lgd_206
 
E/M Inpatient Consult

The only time he does not have to include ROS is when he states unable to attain ROS due to poor historian. Also, the same with PFSH, he can eliminate that if he states that.
He will get credit if those terms are used. One of the reasons he cannot get that information is if the patient is unconscious, dementia, amnesia and cases like that. If he includes two or three in the ROS as he can tell a few systems by examining the patient he can also say all other systems unable to attain due to:
If he refers to a ROS that is in the office, I know he can refer to it with the date of the documentation of that ROS. But, I am not quite sure he can use it for a hospital note but he can use it for office note to office note.
 
ROS inpatient consult

Yes he would have to support at least 2 ROS to bill the lowest level initial visit 99221 for inpt services. This can be found in the HPI you can't use the same positive/negative ROS as an element such as associated sign or symptom.

1995 guidelines;
!DG: A ROS and/or a PFSH obtained during an earlier encounter does not need to
be re-recorded if there is evidence that the physician reviewed and updated
the previous information. This may occur when a physician updates his or
her own record or in an institutional setting or group practice where many
physicians use a common record.


What would need to be supported in the documentation;
To use another physician records according to 95 guidelines he would have to document the following to support both elements have to be supported.

? describing any new ROS and/or PFSH information or noting there
has been no change in the information; and
? noting the date and location of the earlier ROS and/or PFSH.


Goodluck in educating your providers:eek:
 
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